Indexing & Abstracting
Research ArticleDOI Number : 10.36811/gju.2022.110015Article Views : 0Article Downloads : 2
Could intra-peritoneal bladder perforation be treated conservatively?
Urology Speciality Doctor, Warrington and Halton Teaching Hospital NHS Foundation Trust, UK
*Corresponding Author: Hani Sayedin M.Sc, FRCS (Urol), Urology Speciality Doctor, Warrington and Halton Teaching Hospital NHS Foundation Trust, UK, Tel: 00447961998033; Email: email@example.com
Aritcle Type: Research Article
Citation: Hani Sayedin. 2022. Could intra-peritoneal bladder perforation be treated conservatively?. Glob J Urol. 4: 07-13.
Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Copyright © 2022; Hani Sayedin
Publication history:Received date: 22 December, 2022
Accepted date: 27 December, 2022
Published date: 30 December, 2022
Trauma exposure results in variable effects depending on trauma nature, momentum, and the patient general condition. Urinary bladder trauma is more commonly related to abdominal trauma and bladder injury is seen in 1.6% of blunt abdominal trauma. In addition, the urinary bladder is the most common urologic organ subjected to iatrogenic injury. The bladder trauma is classified conventionally into extra-peritoneal, intra-peritoneal or combined trauma. For each category, there are established guideline lines for the proper management. For instance, there is well established agreement for the extra-peritoneal bladder injury to be treated conservatively in absence of other organ damage. While the intraperitoneal bladder injury is recommended to be treated immediately with surgical repair. However, there are many reports might prove the success of the conservative management. Therefore, it is important to highlight the factors that might be addressed for the conservative management trial, considering the fact not every patient would be fit for surgical interventional.
Keywords: Bladder Injury; Intra-Peritoneal Bladder Perforation; Genitourinary Trauma; Conservative management of trauma
Variable mechanisms of bladder injury have been documented. Bladder trauma is mainly associated with abdominal trauma either blunt, penetrating, or iatrogenic injury. Intraperitoneal bladder perforation represents 30% of bladder trauma . Cystography is the gold standard investigation to diagnose intraperitoneal bladder injury. There is a consensus that most of the extra-peritoneal injuries could be treated conservatively with catheter drainage, provided that there is no other cause requiring exploration . In contrary, the intraperitoneal rupture is associated with severe complications, particularly peritonitis. Therefore, open surgical exploration, or laparoscopic, might be recommended [3,4]. The rational of the surgical intervention is to explore the abdominal cavity for assessment of other organ damage, to repair the bladder injury, and to insert peritoneal drain which will prevent and treat associated peritonitis. With carful patient selection, these reasons could be achieved without need for open surgery. CT scan facility has the advantage of being available and highly sensitive to assess abdominal organ damage. Besides, peritoneal drain could be inserted with assistance of interventional radiologist without need for open surgery. Few reports discussed the option of conservative management of the intraperitoneal bladder rupture. However, surgical repair should be offered in case of clinical deterioration. This review highlights the outcome of many reports of cases of intraperitoneal bladder injury that was managed conservatively.
Material and Methods
There are many reports that discuss the option of conservative management of an intraperitoneal bladder perforation (IPBP). Almost all these reports are case reports which is expected in trauma-related topics. In addition, there are different types of clinical scenarios could lead to IPBP including spontaneous, blunt trauma, and iatrogenic trauma. Therefore, the review is presented and classified based on these clinical scenarios. 28 case reports were included in this review, in addition to a cohort study, discussing the role of conservative management of IPBP. We acknowledge that this review has some limitations including the small number and the type of the included studies which may hinder the quality of generated evidence.
Two groups of intra-peritoneal bladder rupture are described; paediatric and adult, the latter group can be further subdivided into spontaneous and traumatic rupture. Osman et al published a study of eight children who presented with an isolated intra-peritoneal bladder rupture . One group was treated conservatively with a urethral catheter and a percutaneous peritoneal drain; the other group underwent conventional open repair. The authors concluded that conservative management might be a valid option in children provided there is adequate bladder drainage, reasonable peritoneal drain output and clinical improvement. Yogo et al reported a three-yearold child with an isolated intra-peritoneal bladder injury . The patient was successfully managed with a urethral catheter and a drain. From these reports, conservative management in the paediatric age group could be considered as an option following an isolated intraperitoneal bladder injury.
Spontaneous intra-peritoneal bladder rupture (SIPBR)
SIPBR is not uncommon cause of bladder rupture and can be associated with diseased bladder, secondary to malignancy, irradiation, or a bladder diverticulum. The presence of systemic disease such as diabetes mellitus and neurological conditions can add to the risk. Ottesen and Iversen reported a spontaneous bladder perforation in a 69-year old male with neurogenic bladder dysfunction secondary to multiple sclerosis that resulted in peritonitis . The rupture followed an episode of urinary retention. Basiri and Radfar reported a spontaneous bladder perforation in a 65-yearold male patient two years post radiotherapy for prostate cancer . The patient was treated successfully with conservative management including antibiotics and a urethral catheter for five weeks, without the need for peritoneal drainage. Craggs and Michielsen reported an intra-peritoneal bladder perforation in a 56- year-old man with a history of an anterior rectum resection and partial cystectomy for a tumour infiltrating the bladder . The rupture occurred one-year postoperatively and without any preceding trauma. The patient was treated conservatively with a urethral catheter and antibiotics, without peritoneal drainage.
Limon et al reported a 52-year-old woman with a history of diabetes mellitus who developed a spontaneous bladder rupture resulting in death . Surgical management was attempted, and a partial cystectomy was performed. The histopathology revealed coagulative necrosis of the bladder with positive bacterial culture in necrotic tissue. These findings could be explained by microangiopathy with subsequent bacterial infection. Kabarriti et al reported a case where a spontaneous bladder rupture in a 36-year old male was also the first presentation of diabetes mellitus . There was a concern about presence of hemoperitoneum and the patient was managed surgically. Shah et al reported another spontaneous rupture in a 43-year-old Caucasian woman with a history of multiple sclerosis ; conservative management failed after 14 days and the delayed diagnosis and surgical management led to a prolonged hospital stay. In 2015, Sawalmeh et al reported another case of spontaneous bladder rupture in a 67-year-old man with a history of diabetes and a subsequent literature review recommended that surgical management should not be postponed .
Conservative management may be applicable in highly selected cases where the presentation is subacute, and the patient’s condition is stable. Close observation is mandatory and conversion to surgical management should not be postponed if the patient shows any signs of clinical deterioration. In the reports of successful conservative management [8,9], the patients were not reported to have diabetes mellitus which may be a negative prognostic factor [10,11,13].
Traumatic intra-peritoneal bladder rupture (TIPBR)
TIPBR can be blunt, penetrating, and iatrogenic. Blunt trauma in adults can be severe leading to a large perforation requiring surgical repair  and very few publications reveal successful conservative management. In 1974, Mulkey and Witherington described the successful conservative management of intraperitoneal bladder rupture in eight patients . Hayakawa et al reported successful conservative management of TIPBR to a 32- year old male patient  secondary to a fractured pelvis and a pelvic hematoma. The rationale for conservative management was to avoid infection and bleeding Geng et al reported the late presentation of TIPBR in a 48- year old male patient who had blunt abdominal trauma and was treated successfully by conservative management . The patient had initially urethral catheter for five days and then presented two weeks following the traumatic event with abdominal pain and ascites. The late and subacute presentation may have influenced the conservative management decision. Shafi et al reported another identical and successful case of conservative management in a 72-year old male patient . However, the decision for conservative management was influenced by the patient’s poor general condition.
European association of Urology (EAU) guidelines in 2021 recommended surgical management for TIPBR caused by blunt abdominal trauma utilizing an open or a laparoscopic repair . For penetrating trauma, they recommend open surgical exploration. Iatrogenic TIPBR can be related to gynaecological and urological procedures . These types of injury should be repaired once diagnosed . Trans-urethral resection of bladder tumour (TURBT) has a risk 1-5% of bladder injury . However, there might be underestimation for the real bladder injury post TURBT. Balbay et al performed cystography following TURBT in 36 patients. The authors found that there was extra-peritoneal extravasation of contrast in 21 patients (58.3%) . interestingly, the extravasation was not associated with extra-vesical tumour seeding. Perforations requiring open intervention are however rare (0.36%) . Open repair may be needed with a large bladder perforation especially in the elderly with large posterior wall tumours. However, there may be a risk of extra-vesical tumour cell recurrence with a negative impact on the prognosis . Conservative management of TURBT related intra-peritoneal bladder rupture has been described with a successful outcome . Manikandan et al reported successful conservative management of three patients who developed symptomatic iatrogenic TIPBR ; all the cases had a peritoneal drain [24,25].
Most urologists might experience a small perforation following a deep resection during TURBT but most of these perforations will be extra-peritoneal  and can be managed conservatively. Iatrogenic bladder injury is one of the most common complications post gynaecological procedures. Thiagarajan et al managed TIPBR post caesarean section conservatively . A 30-year-old lady developed ileus 2 days post operatively and CT cystogram showed 6 mm tear in the bladder dome. Undoubtedly, the small-sized tear was an important factor for successful conservative management with urethral catheterization, and with no further need for peritoneal drain. Catheter induced intra-peritoneal bladder injury could happen in rare clinical scenarios, mostly secondary to long-term catheterization . Zhan et al reported successful conservative management of catheter induced intraperitoneal bladder rupture . This report showed the importance of a CT scan to achieve the diagnosis. The author experienced a trial for conservative management of catheter-related intraperitoneal bladder perforation . However, this trial was not successful, and the patient was managed by laparoscopic bladder repair. The main reason for the conversion to surgical management was the worsening abdominal pain and developing peritonitis symptoms. Unfortunately, the option of intra-peritoneal drain was not available which might change the outcome. There are also reports that document long-term catheter induced extra-peritoneal bladder rupture .
Yi-Chun Lin and Yen-Chung Lin reported the successful conservative management of catheter induced TIPBR in a 93-year-old male . The patient presented with haematuria and bladder irrigation was commenced. A cystoscopy revealed a perforated bladder ulcer and after the procedure, he developed abdominal pain but was treated conservatively considering the small injury and his age. Catheter related intraperitoneal bladder rupture, either spontaneous or traumatic can present with altered mental status, haematuria, sepsis and abdominal pain. Medical fitness and an early diagnosis may influence the outcome. Trauma effect would be variable and depends on trauma type and momentum, the age and the general medical condition of the patient. Therefore, Individual clinical assessment and management of every patient should be adopted. Contrast CT and a cystogram should be performed to confirm the diagnosis of an isolated bladder injury. If conservative management is contemplated, the patient should be hemodynamically stable and under close observation with adequate bladder drainage and "ideally" a peritoneal drain. Nevertheless, surgical intervention should be offered without delay in case of clinical deterioration.
Laparoscopic bladder repair
It could be of enormous value to consider laparoscopy in case of surgical decision. Laparoscopic repair of an intra-peritoneal bladder rupture post TURBT and blunt trauma has been reported [31, 32]. Al-Aghbari et al reported successful laparoscopic repair of an intra-peritoneal rupture together with closed reduction of a left hip dislocation . Marchand et al reported another case with a similar history . Laparoscopic repair may be advantageous in these cases as it could avoid bleeding from well-organized pelvic hematoma post pelvic fracture. In addition, EAU guidelines recommended laparoscopic repair in intra-peritoneal blunt non-iatrogenic bladder trauma .
Conservative management of intra-peritoneal bladder perforation might be feasible in highly selected patients. Conditional prerequisites include isolated bladder injury, adequate urinary bladder drainage and stable clinical condition. Peritoneal drain might improve the chances of the success of the conservative trial; particularly if the patient is not fit surgically. However, surgical intervention should be offered once the patient showed deteriorated clinical signs. If surgery is contemplated, a laparoscopic bladder repair can result in a good clinical outcome with the advantages of less post-operative pain and a shorter hospital stay.
1. Teplitsky SL, Leong JY, Shenot PJ. 2020. Iatrogenic bladder rupture in individuals with disability related to spinal cord injury and chronic indwelling urethral catheters. Spinal Cord Ser Cases. 8: 47-10. Ref.: https://pubmed.ncbi.nlm.nih.gov/32513945/ DOI: https://doi.org/10.1038/s41394-020-0296-3
2. Simon LV, Sajjad H, Lopez RA, et al. Bladder Rupture. 2021.
3. Fu CY, Shih CH, Chang PY, et al. 2012. Conservative treatment of concomitant extraperitoneal bladder rupture and intrabladder blood clot formation: Case report of application of ureteral catheterization. Can Urol Assoc J. 6: 256-258. Ref.: https://pubmed.ncbi.nlm.nih.gov/23283098/ DOI: https://doi.org/10.5489/cuaj.11095
4. Kong JP, Bultitude MF, Royce P, et al. 2011. Lower urinary tract injuries following blunt trauma: a review of contemporary management. Rev Urol. 119-130. Ref.: https://pubmed.ncbi.nlm.nih.gov/22114545/
5. Osman Y, El-Tabey N, Mohsen T, et al. 2005. Nonoperative treatment of isolated posttraumatic intraperitoneal bladder rupture in children-is it justified? J Urol. 173: 955-957. Ref.: https://pubmed.ncbi.nlm.nih.gov/15711348/ DOI: https://doi.org/10.1097/01.ju.0000152220.3160 3.dc
6. Yogo N, Toida C, Muguruma T, et al. 2019. Successful Conservative Treatment of Traumatic Intraperitoneal Bladder Rupture in a Child: A Case Report. Case Rep Acute Med. 2: 18-24.
7. Ottesen M, Iversen JT. 1993. Spontan blaereperforation--en sjaelden komplikation til neurogen blaeredysfunktion [Spontaneous bladder perforation--a rare complication of neurogenic bladder dysfunction]. Ugeskr Laeger. 26: 2352-2353.
8. Basiri A, Radfar MH. 2008. Conservative management of early bladder rupture after postoperative radiotherapy for prostate cancer. Urol J. 5: 269-271. Ref.: https://pubmed.ncbi.nlm.nih.gov/19101903/
9. Craggs B, Michielsen D. 2011. Conservative treatment of an intraperitoneal bladder perforation. Cent European J Urol. 47: 9. Ref.: https://pubmed.ncbi.nlm.nih.gov/24578862/ DOI: https://doi.org/10.5173/ceju.2011.01.art11
10. Limon O, Unluer EE, Unay FC, et al. 2012. An unusual cause of death: spontaneous urinary bladder perforation. Am J Emerg Med. 30: 2081-2083. Ref.: https://pubmed.ncbi.nlm.nih.gov/23158061/ DOI: https://doi.org/10.1016/j.ajem.2011.10.030
11. Kabarriti AE, Ramchandani P, Guzzo TJ. 2014. Spontaneous Urinary Bladder Perforation: An Unusual Presentation of Diabetes Mellitus. Urol Case Rep. 16: 109-111. Ref.: https://pubmed.ncbi.nlm.nih.gov/26955559/ DOI: https://doi.org/10.1016/j.eucr.2014.03.005
12. Shah R, Ramakrishnan M, Ahmed B, et al. 2017. Perforated Bladder as a Cause of Abdominal Ascites in a Patient Presenting with Acute Onset Abdominal Pain: Cureus. 11: 1241. Ref.: https://pubmed.ncbi.nlm.nih.gov/28620570/ DOI: https://doi.org/10.7759/cureus.1241
13. Sawalmeh H, Al-Ozaibi L, Hussein A, et al. 2015. Spontaneous rupture of the urinary bladder (SRUB); A case report and review of literature. Int J Surg Case Rep. 16: 116-118. Ref.: https://pubmed.ncbi.nlm.nih.gov/26451645/ DOI: https://doi.org/10.1016/j.ijscr.2015.09.035
14. Mulkey AP Jr, Witherington R. 1974. Conservative management of vesical rupture. Urology. 4: 426-430. Ref.: https://pubmed.ncbi.nlm.nih.gov/4420305/ DOI: https://doi.org/10.1016/0090- 4295(74)90012-0
15. Hayakawa M, Tuchiya K, Hoshino H, et al. 2007. Non-Operative Management of a Blunt Traumatic Intraperitoneal Bladder Rupture as Damage Control after a Severe Pelvic Fracture.J-stage (Nihon Kyukyu Igakukai Zasshi. 18: 23- 26.
16. Geng JH, Chang HC, Chung SD, et al. 2014. Nonoperative treatment for intraperitoneal bladder rupture. Urological Science. 25: 70-72.
17. Shafi H, Darzi A, Ahangar S, et al. 2017. NonOperative Management of Intraperitoneal Bladder Rupture Due to Blunt Abdominal Trauma. Trauma Mon. 22: 38079.
18. European Association of Urology. 2022. Urological Trauma - INTRODUCTION - Uroweb
19. Lee JS, Choe JH, Lee HS, et al. 2012. Urologic complications following obstetric and gynecologic surgery. Korean J Urol. 53: 795- 799. Ref.: https://pubmed.ncbi.nlm.nih.gov/23185673/ DOI: https://doi.org/10.4111/kju.2012.53.11.795
20. Collado A, Chéchile GE, Salvador J, et al. 2000. Early complications of endoscopic treatment for superficial bladder tumors. J Urol. 164: 1529-1532. Ref.: https://pubmed.ncbi.nlm.nih.gov/11025697/
21. Balbay MD, Cimentepe E, Unsal A, et al. 2005. The actual incidence of bladder perforation following transurethral bladder surgery. J Urol. 174: 2260-2262. Ref.: https://pubmed.ncbi.nlm.nih.gov/16280794/ DOI: https://doi.org/10.1097/01.ju.0000181811.6119 9.35
22. Golan S, Baniel J, Lask D. 2011. Transurethral resection of bladder tumour complicated by perforation requiring open surgical repair - clinical characteristics and oncological outcomes. BJU Int. 107: 1065-1068. Ref.: https://pubmed.ncbi.nlm.nih.gov/20860654/ DOI: https://doi.org/10.1111/j.1464- 410x.2010.09696.x
23. Skolarikos A, Chrisofos M, Ferakis N, 2005. Does the management of bladder perforation during transurethral resection of superficial bladder tumors predispose to extravesical tumor recurrence?. J Urol. 173: 1908-1911. Ref.: https://pubmed.ncbi.nlm.nih.gov/15879773/ DOI: https://doi.org/10.1097/01.ju.0000158450.7149 7.ae
24. Pansadoro A, Franco G, Laurenti C, et al. 2002. Conservative treatment of intraperitoneal bladder perforation during transurethral resection of bladder tumor. Urology. 60: 682- 684. Ref.: https://pubmed.ncbi.nlm.nih.gov/12385934/ DOI: https://doi.org/10.1016/s0090- 4295(02)01843-5
25. Manikandan R, Lynch N, Grills RJ. 2003. Percutaneous peritoneal drainage for intraperitoneal bladder perforations during transurethral resection of bladder tumors. J Endourol. 17: 945-957. Ref.: https://pubmed.ncbi.nlm.nih.gov/14744369/ DOI: https://doi.org/10.1089/089277903772036343
26. Thiagarajan SK, Reddy GS, Udbhav KSNS, et al. 2021. Intraperitoneal bladder injury – A conservative approach. J Evolution Med Dent Sci. 10: 3446-3448.
27. Magee GD, Marshall SG, Wilson BG, et al. 1991. Perforation of the urinary bladder due to prolonged use of an indwelling catheter. Ulster Med J. 60: 237-239. Ref.: https://pubmed.ncbi.nlm.nih.gov/1785161/
28. Zhan C, Maria PP, Dym RJ. 2017. Intraperitoneal Urinary Bladder Perforation with Pneumoperitoneum in Association with Indwelling Foley Catheter Diagnosed in Emergency Department. J Emerg Med. 53: 93-96. Ref.: https://pubmed.ncbi.nlm.nih.gov/29128041/ DOI: https://doi.org/10.1016/j.jemermed.2017.06.006
29. Hani Sayedin, Soumendra Datta, Stephen Keoghane. 2021. Laparoscopic Repair of Catheter-Induced Intra-Peritoneal Bladder Perforation. Cureus: Journal of Medical Science. 13: e20096. Ref.: https://pubmed.ncbi.nlm.nih.gov/35003952/ DOI: https://doi.org/10.7759/cureus.20096
30. Lin YC, Lin YC. 2012. Intraperitoneal urinary bladder fistula caused by a Foley catheter: a successfully conservative management. BMJ Case Rep. 30: 0120125630. Ref.: https://pubmed.ncbi.nlm.nih.gov/22669853/ DOI: https://doi.org/10.1136/bcr.01.2012.5630
31. Frachet O, Cordier G, Henry N, et al. 2007. Perforations vésicales au cours d'une résection trans-uréthrale de tumeur de vessie [Bladder perforation during transurethral resection of bladder tumour: a review]. Prog Urol. 17: 1310-1312.
32. May F, Schlenker B, Hofer B, et al. 2013. Laparoscopic repair of iatrogenic bladder perforation during transurethral bladder tumor resection: Case report and literature review. Indian J Urol. 29: 61-63. Ref.: https://pubmed.ncbi.nlm.nih.gov/23671369/ DOI: https://doi.org/10.4103/0970- 1591.109988
33. Al-Aghbari S, Al-Harthy A, Ahmed M, et al. 2011. Laparoscopic repair of traumatic intraperitoneal bladder rupture. Sultan Qaboos Univ Med J. 11: 515-518. Ref.: https://pubmed.ncbi.nlm.nih.gov/22087403/
34. Marchand TD, Cuadra RH, Ricchiuti DJ. 2012. Laparoscopic repair of a traumatic bladder rupture. 1: 155-158. Ref.: https://pubmed.ncbi.nlm.nih.gov/22906346/ DOI: https://doi.org/10.4293/108680812x132915977 16546